Critically Important Claims Management Principles That are Almost Never Used, But Save Lives and Money

At the National Council of Self-Insurers Annual Meeting, Dr. Robert Barth presented a session discussing some medical management issues that can have a significant impact on the well being of injured workers and also save employers money.

Dr. Barth’s main hypotheses were:

• Non-work-related factors are driving the overwhelming majority of workers’ compensation costs.
• Workers’ compensation is inappropriately forcing an injury model on issues that are NOT actually injury-related.
• Workers’ compensation encourages excessive and non-credible treatment.
• Workers’ compensation encourages withdrawal from work.
• Workers’ compensation is actually harmful to the health of workers.

His suggested solutions:

• Do not accept claims as compensable unless accepted medical guidelines indicate the condition is related to employment.  Good example of this is the AMA guides book and newsletter.
• Follow protocol to establish diagnosis, apply relevant findings from scientific literature, assess evidence of exposure, consider other relevant factors, scrutinize the validity of the evidence and, finally, evaluate all of this and generate conclusions.
• Pain complaints, alone, should not be a reason for withdrawal from work. This is counter-productive and harmful for the injured workers. Being unemployed creates additional stressors on the injured worker. Work is good for pain complaints and psychological concerns.
• Need to make sure the physician has complete understanding of the job, including whether the person can do the job and wants to do the job. If they do not want to do the job, are there symptoms to justify this?
• Protect injured workers from harmful treatments for pain (surgery, spinal cord stimulators, pain pumps, excessive prescriptions, etc.). Example, the #1 cause of death for workers who have undergone spinal fusion surgery is narcotics. It is a FACT that opioids do more harm than good for chronic pain. Studies also show fusions lead to longer disability, higher medical complications and increased prescription drug use.
• Consider psycho-social issues, which are the greatest predictor of failures for treatment. This includes history of abuse, excessive alcohol consumption, attorney representation, depression, coping inadequacy, low education, etc. Surgeons almost never evaluate these issues when contemplating spinal surgery, but studies show over 80% of failed back surgeries had significant psycho-social predictors present.
• Back pain, itself, is not a work injury. Job dissatisfaction and depression are the best predictors about who will file a workers’ compensation claim for a back injury.  Back pain is a normal human condition that almost everyone will experience during their lifetime. Studies show that 73% of workers with chronic back pain have a “personality disorder” compared with 10-13% of the normal population.
• The one element that distinguishes accident survivors with low back pain with those that did not have low back pain was “eligibility for compensation.” Clearly, secondary gain is a factor to how people respond to a situation.